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Challenges to achieving low palatal fistula rates following primary cleft palate repair: experience of an institution in Uganda
Katusabe et al. BMC Res Notes
Challenges to achieving low palatal fistula rates following primary cleft palate repair: experience of an institution in Uganda
Josephine Linda Katusabe 0
Andrew Hodges 0
George William Galiwango 0
Edgar M. Mulogo
0 Comprehensive Rehabilitation Services Uganda (CoRSU) Hospital , P.O.Box 46, Kisubi , Uganda
Objective: To determine frequency of palatal fistula following primary cleft palate repair and the associated factors as a measure of cleft palate repair outcome and its challenges at a cleft centre in Uganda. Results: Between May and December 2016, 54 children with cleft palate were followed up at Comprehensive Rehabilitation services of Uganda (CoRSU) hospital, from time of primary cleft palate repair until at least 3 months postoperative to determine whether they developed palatal fistula or not. Frequency of palatal fistula was 35%. Factors associated with increased fistula formation were cleft width wider than 12 mm (p = 0.006), palatal index greater than 0.4 (p = 0.046), presence of malnutrition at initial outpatient assessment (p = 0.0057) and at time of surgery (p = 0.008), two-stage palate repair (p = 0.005) and postoperative infection (p = 0.003). Severe clefting (palatal index greater than 0.4) was seen in 74% of patients and malnutrition (Low weight for age) seen in 48% of patients. Palatal fistula rates at our institution were high compared to reports in literature. The high proportions of severe clefting and malnutrition observed in our population that was also poor and unable to afford feeding supplements increased likelihood of fistula formation and posed challenges to achieving low fistula rates in our setting.
Cleft palate; Primary palate repair; Palatal fistula
Introduction
Palatal fistula is a failure of healing or breakdown in the
primary surgical repair of a cleft palate [
1
]. Palatal
fistula results in persistent communication between oral
and nasal cavities leading to unpleasant symptoms such
as nasal spillage of feeds, hypernasal speech, articulation
problems which undermine the success of palate repair
[
2
]. A low incidence of palatal fistula is one of the
indicators of successful cleft palate repair [
3
].
Incidence of palatal fistula in literature ranges from 0 to
35% [
1, 3–8
] with overall incidence of 8.6% reported by
a meta-analysis of studies in Europe, America, Asia and
Africa [
9
]. Risk factors of palatal fistula reported include
type of cleft, cleft palate width, surgeon’s experience,
timing and technique of repair. There is a paucity of studies
in Africa and Uganda assessing frequency of palatal
fistula and associated factors following cleft palate repair. In
Uganda, reports show that most children with cleft palate
are already malnourished when they first present to
hospital and may continue failing to thrive if no timely
intervention is done [
10–12
]. Effect of this malnutrition on
surgical outcome of palate repair has not been studied.
Our study aimed to determine frequency of palatal
fistula following primary palate repair and the associated
factors at CoRSU hospital in order to assess our cleft
palate repair outcome and also establish the challenges to
achieving low fistula rates.
Main text
Methods
A prospective case series was conducted from May to
December 2016 at CoRSU hospital, a specialized
hospital in Uganda offering free cleft palate surgery. Children
with unrepaired cleft palate, whose caregivers gave
written consent to participate in the study were enrolled and
followed up from time of primary cleft palate repair until
at least 3 months postoperative to determine whether
they developed palatal fistula or not. Primary
palate repair (surgery on cleft palates that have not been
repaired before) was performed either as single-stage
repair of both hard and soft palate or as a two-stage
procedure involving hard palate repair with vomer flap in
first stage and soft palate repair 3 months later in second
stage. Surgical techniques included intravelar veloplasty
for soft palate, Von Langenbeck flaps, Bardarch flaps and
Hybrid flaps for hard palate (see Additional file 1 showing
description of surgical techniques).
Desired perioperative information including age,
weight and length, type of cleft, type of surgery, surgical
technique and surgeon’s experience (based on volume
of palate surgeries performed annually) was recorded in
pretested data forms. Preoperative dental casts of each
palate were made, from which cleft width and palatal
shelf widths were measured using Castroviejo calipers
(see Additional file 2 showing dimensions measured).
Weight for length and weight for age z-scores were
calculated and compared with W.H.O reference values to
determine nutrition status. At postoperative review, a
consultant plastic surgeon inspected the palate using a
clinical torch and tongue depressor to determine
presence or absence of fistulas. Only fistulas posterior to
incisive foramen were considered. Statistical a (...truncated)